Single-Incision Laparoscopic Versus Conventional Laparoscopic Surgery for Rectobladderneck and Rectoprostatic Anorectal Malformations

Introduction

Anorectal malformation (ARM) is one of the most common congenital anomalies occurring in ∼1/5000 to 1/1500 neonates. ¹ It severely influences the quality of life of the patient. Laparoscopic-assisted anorectoplasty (LAARP) was shown to be safe and comparable with the open approach in treating patients with rectobladderneck and rectoprostatic ARM.^2,3 This surgery is usually accomplished through a total of three small incisions in the abdomen to accommodate laparoscopic trocars. Recently, single-incision laparoscopic surgery (SILS) was introduced to further enhance the outcome of LAARP following technical and commercial progress, and has been increasingly utilized in pediatric patients.^4–6 The SILS has been utilized in Roux-en-Y hepaticojejunostomy for choledochal cysts, appendectomy, cholecystectomy, inguinal hernia repairs, and so on.^6–9 SILS has been shown to have the following benefits: reduced number of incisions and tissue trauma, good clinical outcomes and low rate of conversion, decreased morbidity, and improved cosmesis. ¹⁰ For these reasons, we sought to determine whether SILS is comparable with conventional laparoscopy for the repairs of ARM.

Materials and Methods

Surgical technique

Operations in the two groups were performed by the same surgeon in our institution. The procedure of CLAARP was performed in accordance with the conventional technique as described by Georgeson et al. ² In brief, when the bowel was retracted cephalad out of the pelvis, laparoscopic rectal dissection allowed examination of the underlying levator muscles in the pelvic floor. Subsequently, the intrasphincteric plane was dissected bluntly from below to the level of the levator sling using laparoscopic backlighting, the tract was then dilated radially to 10 mm, and the divided rectal fistula grasped and pulled onto the perineum while removing the trocar. Our group has previously established successfully the SILS procedure, which is very similar to the CLAARP, ¹² using a single 1.5-cm horizontal skin incision in the umbilicus for laparoscopic access instead of 8-mm vertical midline incision in CLAARP (Fig. 1). ²

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FIG. 1.

Single-incision laparoscopic surgery with transabdominal retraction suture through the posterior bladder wall.

Postoperatively, an anal tube was inserted and maintained for 5–7 days to promote defecation and prevent anastomotic strictures. Subsequently, an anorectal dilation program was started 2 weeks after operation. The anus and rectum were serially dilated from a size 8 up to a size 12 using Hegar dilators over a 3-month period. The colostomy was closed after the rectum was sufficiently dilated and had reached the desired size.

Results

The demographic features of the two groups are summarized in Table 2. One hundred five children (79 male and 26 female) with mean age of 5.5 months underwent laparoscopic-assisted anorectoplasty: 51 SILS and 54 CLAARP. All the children underwent colostomy.

The associated anomalies between the two groups are listed in Table 3. The spinal anomalies (including partial sacral agenesis, tethered cord, and spinal bifida occulta), cardiothoracic anomalies, and genitourinary anomalies (including vesicoureteral reflux, hydronephrosis, hypospadias, and undescended testis) of the two groups were similar. The operative time in the SILS group (113.5 ± 12.7 minutes) is shorter than that in the CLAARP group (126.2 ± 10.2 minutes) (P = .003). The amount of operative blood loss was 11.6 ± 1.7 mL in the SILS group and 11.8 ± 1.8 mL in the CLAARP group (P = .75). The lengths of hospital stay after the operation were 7.3 ± 1.1 days in the SILS group and 7.6 ± 2.2 days in the CLAARP group (P = .59). The time to resume diet was 9.6 ± 2.4 hours in the SILS group and 10.6 ± 2.1 hours in the CLAARP group (P = .19).

The median follow-up time was 35 months (range 24–40 months) in the SILS group and 43 months (range 24–50 months) in the CLAARP group. The postoperative outcomes are shown in Table 4. Rectal prolapse occurred in 4 of 51 (7.8%) children in the SILS group and in 4 of 54 (7.4%) children in the CLAARP group (P = 1.00). Postoperative pelvic MRI verified that all patients had a centrally placed rectum within the muscle complex. No patients experienced remnants of the original fistula in either group according to voiding cystourethrogram and MRI. Neither group underwent complications such as wound infection and dehiscence, rectal retraction, and recurrent fistula.

The functional results of the two groups are shown in Table 5. Since only patients were older than 2 years, we were able to make a relatively accurate assessment regarding the bowel function, and no patient with soiling grade 3 was included in our research. There were no significant differences in the voluntary bowl movement, soiling, and constipation between the two groups. Six patients in the SILS group and 8 patients in the CLAARP group experienced slight constipation (P = .65), which could be alleviated by nonsurgical methods. No patient suffered severe constipation in either group. Some children underwent varied degrees of soiling in the early postoperative period, but the symptom resolved after 6–12 months of functional training and recovery of anal sphincter function. As functional results improve with time, both groups appeared to deliver better results.

Discussion

LAARP was first introduced by Georgeson et al., ² and CLAARP has been proven to be a safe and feasible approach for rectobladderneck and rectoprostatic-type ARM.^2,13 Compared with posterior sagittal anorectoplasty, the LAARP has its unique benefits, including reduction of surgical trauma, excellent visualization of the rectal fistula and surrounding structures, and accurate placement of the rectum into the muscle complex. ¹⁴ SILS is a relatively new approach for treating ARMs with rectobladderneck and claims to be less invasive than conventional laparoscopic surgery. ¹⁰ SILS has been adopted in various divisions of surgery such as gastroenterology, pancreatology, gynecology, and urology. Its safety and feasibility were tested and compared with conventional laparoscopy in several case studies and case series, and it was shown to be comparable with CLAARP, with the added benefit of improved cosmesis.^15,16

However, it has also some drawbacks such as the interference of instruments, because of the loss of triangulation with conventional instruments, the difficulty of achieving correct exposure and necessary traction to tissues, and the relative small working space. Despite facing such problems, our group has accumulated an adequate experience and skills in using the SILS technique so far. Compared with the settings of conventional laparoscopic, the instruments can reach deeper surgical fields with the lengthened telescope guidance from the same direction, which is suitable to perform in the relatively small and deep fields like the pelvic cavity, especially for fistula dissection and meticulous suture closure in intermediate ARMs. In addition, the method of transabdominal suture retraction through posterior bladder wall can be used to obtain a good laparoscopic view of the pelvic cavity, and we can also pull up rectal blind pouch to the abdominal cavity to identify the rectourethral fistula with intermediate ARMs. The telescope can be rotated by 180°, so that the operation can be easily carried out.

Postoperative MRI verified the central placement of the rectum within the pelvic muscle complex. The procedure of LAARP can bring the terminal bowel into the center of muscle complex exactly. No recurrent fistula and remnants of the original fistula occurred in ARM patients with either rectoprostatic or rectobladderneck fistula according to voiding cystourethrogram, probably due to the adequate mobilization of the rectum. A precise understanding of the anatomic relationships can help avoid injuries to urethra and bladderneck during the procedure LAARP. To prevent the posterior remnant of the original fistula, the fistula should be sutured adjacently to the urethra. In our research, the mucosa at the end of fistula was destroyed, which lowered the incidence rate of recurrent fistula and remnant of the original fistula.

Four patients (7.8%) were accompanied with rectal prolapse in SILS group, while 7.4% patients in the CLAARP group, which was consistent with previous reports.^17,18 Previous literature has suggested that rectal prolapse is related to the excessive mobilization of the rectum and its inadequate fixation. Thus, the dissection of rectum and pelvic structures should be meticulous, and the rectal fixation with seromuscular sutures between the rectum and the presacral fascia. ¹⁸ In addition, the symptom of rectal prolapse is more common in patients with higher incidence of malformations and with poor sacral and pelvic musculature. ¹⁹ Furthermore, 5 of 8 patients with rectal prolapse had partial sacral agenesis, and no wound infection/dehiscence, rectal retraction, and anastomotic stricture occurred in either group, which is a result of mobilized distal rectum and tension-free anastomosis.

In this study, we did not find differences regarding the surgery itself, namely complications during the operation, conversion rate and lengths of hospital stay after the operation, postoperative complications, and bowel function. Six patients in the SILS group and 8 patients in the CLAARP group experienced slight constipation during the follow-up period. The symptom of constipation was alleviated through the methods of diet control, laxative and anal dilation. No patients underwent severe constipation in either group. The symptoms of fecal incontinence and constipation following surgical procedures have been troublesome to many patients with ARMs. Iwanaka et al. ²⁰ recommended LAARP as an alternative procedure for its minimal damage to the sphincter muscles and tiny nerves. One of the most important factors that influence defecation is the striated muscle complex. Therefore, we did our utmost to avoid injuring the striated muscle complex and nerves around the puborectalalis muscles during the procedure of laparoscopic surgery, which is an important determination of the surgery outcomes.

In conclusion, both procedures had similar medium-term outcomes and complications. Due to the existence of colostomy in the patients of the two groups, the cosmetic advantages of SILS were not that obvious. The main advantage of SILS may be that it can reduce ports and stab incisions. For the experienced endoscopic surgeons, SILS is safe and effective for patients with rectobladderneck and rectourethral fistula ARMs. The SILS might be an alternative surgical treatment. Limitations of this study are mainly due to its retrospective nature and relatively small sample size. A large prospective randomized study and long-term follow-up studies should be conducted clinically to demonstrate the significant differences between the SILS and CLAARP procedures for the different types of ARMs.

Authors' Contributions

H.X. carried out the entire procedure, including the literature search and data extraction, and performed the statistical analysis, drafted the article, and submitted the revised article. L.L., M.D., conceived of the study, coordinated and participated in the entire process of drafting, and revised the article. R.H., X.C., and L.C. contributed to statistical analysis and revision of the article. H.X. and L.L. contributed to the revisions of the article. All authors have contributed significantly. All authors read and approved the final article.